SCOPE | Provider Update

July 2024

Clinical Matters

Care coordination is integral to patients' health and recovery

While lack of coordination leads to negative outcomes, communication and coordination lead to better chances for improved outcomes.

Independent Health has long recognized that when doctors and other health care providers work together and share patient information, the patients’ needs and preferences are made known and communicated at the right time to the right people, and the information is used to provide safe, appropriate, and effective care. This can help to keep patients healthier longer, better manage chronic conditions and experience care that is consistent with their goals.

When doctors and other health care providers don’t communicate effectively with each other, treatments prescribed by different doctors for a patient’s different health issues might conflict or become unmanageable for the patient. Lack of coordination can lead to negative health outcomes for patients, such as:

Increased use of emergency care
Medication errors
Poor transitions of care from hospital to home, or other setting
Medical errors
Readmissions

These effects can have a larger negative impact on chronically ill patients or patients with multiple complex health conditions.

Discharge from a hospital is a critical transition point in a patient’s care. Poor care coordination at discharge can lead to adverse events for patients and avoidable rehospitalization. Health risks associated with hospitalization include infection, adverse drug events, loss of function, isolation and negative quality of life, and readmission.

Medication reconciliation also plays an integral role. This process is important to improve patient safety, for identifying and resolving discrepancies, such as duplicates, omissions, or incorrect dosages. By helping to reduce medication errors and adverse drug outcomes, patient safety is preserved.

Ideas for providers to help improve care coordination

Use Care Coordinators or assign designated staff to improve care coordination efforts.
Use a universal EHR care coordination screening tool.
Build digital tools that allow care coordinators, social workers, and providers to identify community partners that address social determinants of health and make direct referrals.

Independent Health’s efforts to improve care coordination

At Independent Health, we have led or participated with several initiatives to advance care coordination. In 2021, Independent Health and ECMC collaborated on an opportunity to create and implement a solution to address the challenge of costly patient readmissions. ECMC implemented a care transition pilot program focused on our members in need of this high-touch and closely coordinated care. The care team of ECMC clinicians and support professionals proactively worked with the most acute/high-risk members on a care plan for discharge and 30-day follow up. The pilot with Independent Health proved to be so successful, ECMC was recently awarded $8.3 million in funding from New York State to expand its care transitions program to reduce avoidable readmissions for all its patients.

Independent Health’s Care for You program helps our members with chronic health conditions get the medical care and assistance they need without having to navigate the health care system alone. To address the specific and extensive care required by individuals with multiple chronic conditions, Care for You involves a dedicated care team of physicians, physician assistants, nurse practitioners, registered nurses, social workers, dietitians, and community health workers who work with the patients to develop individualized, proactive care plans in concert with their primary care physician. Care for You enhances access to the most appropriate care for individuals in order to reduce hospitalizations, readmissions and emergency room visits by wrapping around the delivery system to help enhance coordination and communication.

Independent Health offers a variety of case management programs that can assist providers to coordinate appropriate care for their patients. Programs are coordinated by licensed health professionals who include Registered Nurses, a Certified Diabetic Educator/Registered Dietitian, Exercise Physiologist and Behavioral Health Specialists.

For additional information and resources, please visit:

Care Coordination | CMS

Introduction | Agency for Healthcare Research and Quality (ahrq.gov)

Erie County Health Department issues Tuberculosis health advisory

The Erie County Department of Health is monitoring an increase in Tuberculosis (TB) cases. Rapid identification of cases is essential in controlling the spread of TB.

The Erie County Department of Health (ECDOH) is experiencing an increase in Tuberculosis (TB) cases. Rapid identification of cases is essential in controlling the spread of TB. With the increase in TB cases, early detection, treatment, reporting and the management of cases and contacts are essential in preventing serious medical problems and the further spread of the disease.

Providers must report suspected and confirmed cases of TB immediately to the county where the patient resides.

Download and distribute the full advisory from the ECDOH about who should be considered for testing, types of screening tests and how to report cases to the ECDOH.

Follow all NYSDOH and ECDOH bulletins here.

Resources to help prevent HPV cancers

As a supporter of the NYS Start at 9 campaign, Independent Health encourages parents and guardians to discuss the importance of starting the HPV series at age 9.

In the United States, Human Papillomavirus (HPV) infects about 13 million people each year, and about 36,500 people will develop cancer as a result. Several barriers to HPV vaccination exist at the patient, provider, and systems levels. However, providers can overcome or address many of these barriers.

Independent Health is pleased to be part of the New York State "Start at 9" Campaign to Prevent HPV cancers. As a supporter of this campaign, we encourage providers to talk with parents or guardians about the importance of the vaccine to reduce the risk of HPV-related cancers. The latest research also suggests that starting the HPV vaccination series at age 9 can increase the percentage of your patients that are up to date by age 13.

We have developed an HPV Toolkit that includes practical ways to address barriers by communicating clearly with patients and adopting interventions such as provider prompts and standing orders along with Independent Health’s commitment to improve HPV vaccination gap closure.

Please share this with all clinicians in your practice.

View and Download the Toolkit.

Addressing Behavioral Health in the Primary Care Setting

As mental health needs grow, primary care practices are sometimes the first entrypoint for connecting patients to care.

In 2021, in the United States, 22.8% (57.8 million) of adults aged 18 or older were diagnosed with a mental illness. Yet, less than half (47.2%) of adults with mental illness receives mental health services.

Primary care settings are increasingly the first place where behavioral health conditions are identified. Patients present to primary care for both behavioral and physical health conditions. As their patients’ trusted provider, PCPs can identify a concern early and refer to treatment.

Behavioral health screenings in the primary care setting allow for early identification and intervention. Addressing behavioral health services in primary care reduces stigma. Treating common behavioral health disorders in primary care is cost effective.Patients linked with both primary care and behavioral health specialists have better outcomes.

Detailed Web Resources Available Online

Independent Health's behavioral health team has compiled helpful resources for primary care practices.

We encourage you to view this page in the provider portal under Resources/Behavioral Health where you can easily access:

Screening Tools to consider
The NYSDOH Authorization for Release Form
Link to and information about the Matters Network
HEDIS Measures Definitions

Our Behavioral Health Case Management Team is available at (716) 529-3945, Monday through Friday 8 a.m. to 4 p.m. to answer any questions you may have about your patients’ access to BH treatment and resources.

Clinical Practice Guidelines Update

Updated guidelines for Hepatitis and STI screening recommendations; kidney disease; obesity treatment.

The Clinical Practice Guidelines (CPG’s) have been reviewed and approved by IH Quality Performance Committee and updated, where necessary. Changes include adoption of the following guidelines:

Testing Recommendations for Hepatitis C Virus Infection (CDC 2023)

2024 Kidney Disease, Improving Global Outcomes (Kdigo)

Obesity: American College of Cardiology (ACC)/American Heart Association (AHA)/The Obesity Society (TOS), and the other by the American Association of Clinical Endocrinologists (AACE)/American College of Endocrinology (ACE) A Review of Current Guidelines for the Treatment of Obesity (ajmc.com) 2022

STI Screening Recommendations (cdc.gov) (CDC 2022)

To view the updated clinical practice guidelines, please log in to the provider portal. Go to Policies & Guidelines>Clinical Practice Guidelines.

Look for opportunities to limit risky medication combinations in older adults

Guidelines for safe prescribing

Anticholinergic Agents

Anticholinergics have consistently appeared on the Beers Criteria as potentially inappropriate medications for older adults due to their heightened sensitivity to side effects from these medications. These adverse effects include tachycardia, urinary retention, constipation, dry mouth, blurred vision, exacerbation of narrow-angle glaucoma, cognitive impairment, psychomotor slowing, confusion, sedation, and delirium.

Current guidelines advise avoiding the concurrent use of two or more anticholinergic drugs due to the elevated risk of these side effects, particularly cognitive decline (such as delirium, dementia, and cognitive impairment). The longer these medications are used, the greater the associated risk.

To promote safer prescribing, limit anticholinergic medication use in individuals over 65 and consider deprescribing when feasible. When an anticholinergic drug is necessary, recommend using the lowest effective dose for the shortest duration and regularly reassessing its benefit. Additionally, explore alternative agents with lower anticholinergic activity to minimize or eliminate the anticholinergic burden.

Below is a list of alternatives for reference:

High Risk Anticholinergic Medications	Safer Alternatives
Antidepressants: amitriptyline, desipramine, amoxapine, clomipramine, doxepin, imipramine, trimipramine, nortriptyline, paroxetine	Sertraline, escitalopram, venlafaxine, trazodone, duloxetine
Muscle Relaxants: cyclobenzaprine, orphenadrine	Treat underlying problem with non-pharmacologic treatment physiotherapy, heat, or cold application; correct seating and footwear For spasticity: antispasmodics like baclofen or tizanidine
Antihistamines: brompheniramine, chlorpheniramine, cyproheptadine, dimenhydrinate, diphenhydramine (oral), doxylamine, hydroxyzine, meclizine, triprolidine	Alternative antihistamines: loratadine, fexofenadine, cetirizine For anxiety: escitalopram, venlafaxine, duloxetine, or buspirone For sleep: low dose trazodone For nausea: ondansetron or granisetron
Antiparkinsons agents: Benztropine, trihexyphenidyl	For extrapyramidal disorders caused by antipsychotic medications: decrease antipsychotic dose or switch to atypical antipsychotic such as risperidone or aripiprazole.
Antipsychotic Medications: chlorpromazine, olanzapine, clozapine, perphenazine	Alternative atypical antipsychotics: risperidone or aripiprazole. Caution with all antipsychotics especially in elderly with dementia.
Antimuscarinics (urinary incontinence) medications: darifenacin, fesoterodine, flavoxate, oxybutynin, solifenacin, tolterodine, trospium	Nonpharmacological interventions: lifestyle interventions (dietary modifications, weight loss, fluid restriction), bladder training, pelvic floor muscle training and other physical therapy Pharmacologic alternative: Myrbetriq
Antispasmodic Medications: atropine, dicyclomine, clidinium-chlordiazepoxide, homatropine, hyoscyamine, scopolamine	Use lowest effective dosage for shortest duration possible; make sure still indicated & necessary
Antiemetic Medications: prochlorperazine, promethazine	Ondansetron or granisetron

Opioids & Benzodiazepines

Simultaneous use of opioids and benzodiazepines raises the risk of potentially fatal severe respiratory depression or overdose. According to the 2023 Geriatric Beers Criteria, healthcare providers should avoid prescribing opioid pain medications and benzodiazepines together whenever possible, except when patient circumstances necessitate appropriate concurrent use (e.g., severe acute pain in a patient on long-term, stable low-dose benzodiazepine therapy).

For chronic pain management, non-pharmacologic options include acupuncture, chiropractic care, cold and heat therapy, exercise, movement, massages, occupational therapy, physical therapy, rehabilitation therapy, and high-tech treatments using radio waves and electrical signals.

Cognitive behavioral therapy has demonstrated effectiveness in treating depression, anxiety, stress, and chronic pain. As safer alternatives for anxiety treatment, consider escitalopram, venlafaxine, duloxetine, or buspirone.

The CDC recommends tapering opioid medications before tapering benzodiazepines due to the higher risks associated with benzodiazepine withdrawal compared to opioid withdrawal.

To learn more, here is a link to deprescribing resources and guidelines.

Update to timely filing requirements due to ongoing Change Healthcare incident

As health care providers continue to face challenges with claims submissions, Independent Health has once again extended timely filing deadlines.

Independent Health continues to monitor the effect of the Change Healthcare cybersecurity event on some providers’ ability to submit claims to Independent Health.

Independent Health had previously extended timely filing through the end of May with an additional extension through June. We have once again extended the timely filing relaxation period to July 31, 2024.

During this extension period, Independent Health will treat submissions for dates of service on and after the dates below as timely filed claims:

Medicare and State Products = November 23, 2023
Commercial Products = October 24, 2023

The approach remains the same: capture the earliest possible date of service for a still-timely claim as of February 21, 2024, which was the date the Change Healthcare cyber event occurred.

Independent Health may end the extension period earlier if billing is fully restored; additionally, we will consider continuing the timely filing extension period if the disruption continues beyond July 31, 2024.

Self-funded line of business:

Timely filing requirements for our self-funded line of business vary, and requests for reconsideration of untimely claims for self-funded clients will be reviewed on a group-specific basis.

If you have any questions or concerns, please contact Provider Relations Monday through Friday from 8 p.m. to 6 p.m. at 716-631-3292.

In addition, you may visit this page for additional information on claims and billing alternatives.

Upcoming member campaigns to encourage our members to take greater control of their health

Throughout the year, the Health Care Services and Population Health Management Departments deploy various tactics to encourage members to take a more active role in their health.

Gap in Care Reminder Calls

Independent Health’s Member Servicing team will perform telephonic outreach to provide education and encourage members with an open gap in care to reach out to their provider to schedule the appropriate appointments and/or get a prescription to complete the screening.

Medicaid Managed Care members who have open gaps for: breast cancer, colorectal, and/or cervical cancer screenings.
Medicaid Managed Care and Child Health Plus members (ages 9-12) who have started but not completed the series for HPV vaccinations.
Medicare Advantage members who have open gaps for: breast cancer, colorectal, and/or eye exams for members with diabetes.
Timeframe: Call campaign began in June and is continuing in July.

Social Determinants of Health Screening

This telephonic outreach campaign will engage targeted Medicare Advantage members in a conversation around screening for social determinants of health to identify any needs the member has for food, housing, and/or transportation. If a need is identified, Independent Health will assist the member in making a connection to a community resource to address the need.

Outreach method: Outbound telephone call campaign.
Target members: Medicare members identified with social risk factors including those with low-income subsidy or dual enrollment in Medicaid.
Timeframe: Campaign began in June and will run throughout 2024.

Formulary and Policy Changes

Stay up-to-date on Independent Health's pharmacy policies and formulary updates.

Policy Changes

We have made policy changes for the second quarter of 2024; please log into the provider portal to view all drug policies and second quarter changes.

Formulary Updates

The following documents are available in PDF. Please download them, as they contain important information and updates.

Medicare Advantage formulary deletions for individual & group plan members, effective July 1, 2024.
Pharmacy Benefit Dimensions 3-Tier formulary deletions, effective July 1, 2024.
Pharmacy Benefit Dimensions 5-Tier formulary deletions, effective July 1, 2024.

View the most up to date versions of Independent Health’s policies when logged in to our provider portal.

Magellan Rx, administered by Magellan Rx Management, reviews select specialty drug prior authorization requests on Independent Health’s behalf. To view Magellan Rx policies for the drugs that they review, click here.

Independent Health's drug formularies
Access Independent Health's drug formularies here.

To obtain a hard copy, please contact Independent Health Provider Relations by calling (716) 631-3282 or 1-800-736-5771, Monday through Friday from 8 a.m. to 6 p.m.

In the News

Program brings wellness tools, screenings to underserved communities - The Buffalo News, June 4, 2024

Started in 2006, Good for the Neighborhood is one of the longest-running programs at the Independent Health Foundation, the community outreach arm of the regional health insurance company....